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BI
HealthServices,
RAL
Pre-AppointmentInformation
Date
Child's Name:
Gender:
ftvtale
!Female
Dateof Birth:
Marital Status:
Parent/Guardian's Name:
Cityi
Street:
Home Phone:
Age:
Zip Code:
BusinessPhone:
Cell:
Pleaseindicate any restrictions for leaving messages:
How did you hear about us?
Address and phone number of person who referred
We would like to obtain someinformation from you about this child's developmentand presentproblerns(in order to
provide the bestpossibleevaluation). This questionnaireis to be filled out by the child's motheror otherpersonwho can
bestdescribethe child's presentproblems.
School:
EmergencyContact:
School Hours:
Phone:
Relationship to Child:
If parents are separated/divorced,who has custody?
(You will need to provide legal documentation of custody arrangementsbefore your child can be seen.)
PrimaryPhysicran:
Medical Problems:
Medications:
Pleasedescribein your own words why you want your child to be seenat this time:
First, we would like you to answerall of the questionson this pageto tell us aboutyour child's development.Placean
'X' in the yes or no colunm for eachitem. Somequestionsrequirean approximateageor anotler number.
PREGNAI\CY
During the pregnancy, did this child's mother:
HaveGermanmeasles?
Haveanemia?(low iron)
Havediabetes?
Haveanykidneyproblems?
Useany drugsor medicine?
Drink alcohol?
Havehigh blood pressure?
Havea high fever(103 or higherfor 3 daysor more)?
YES
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NO
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DON'T KNOW
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Have any severeemotional problems?
Have any vaginal infection, discharge,or bleeding?
Hasthis child's mothereverexperienced
a miscarriage?
Wasthe miscarriagefrom: lastpregnancybefore this child?
nextpregnancyafter this child?
anyotherpregnancy?
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Smoke?
Take any medicine?
Post-partumdepression?
BIRTH
About how long was this child's mother in labor?
Wasanestheticusedduringdelivery?
Did the babyhaveanyproblemsbreathingat birth?
Did the babyneedblood at birth?
Wasthe babyplacedin an incubator?
How muchdid thebabyweigh at birth?
Werethereany injuries to the baby at birth?
Wasan operationperformedto deliverthe baby?
Wereandinstrumentsusedto deliverthe baby?
Did thebabyhaveyellowjaundiceat birth?
# of Hours
YES
NO
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DON'T KNOW
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MEDICAL HISTORY Has your child ever had the following?
.
YES
NO
Measles?
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ChickenPox?
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Scarletfever?
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Rheumaticfever?
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Allergiesto food?
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Otherallergies?
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Spellsof vomitingt
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Asthma?
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Blow on the head?
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High fever (104 or higherfor 3 daysor more)
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Medicationfor behaviorproblem?
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What medication?
When started?
or convulsiottt?
Seizures
Anemia(low iron or sicklecell)?
Repeatedor prolongedhospitalization?
Tics andtwitches?
RoutineMedications?
History of trauma?
History of abuse?
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DEVBLOPMENT At about what agedid your chitd first:
Sit up?
Years?
Crawl?
Years?
Years?
Years?
Years?
Years?
Years?
Years?
Years?
Years?
Years?
Years?
Walk by self?
Feedself?
Speakfirst real words?
Speakfirst real sentences?
Become completely toilet trained?
Ride a bicycle?
Has your child: been in Special Education?
repeateda grade?
been tested?
beencalled"gifted"?
Months?
Months?
Months?
Months?
Months?
Months?
Months?
Months?
Months?
Months?
Months?
Months?
Was your child, as an infant: reactive, intense, frdgety, and hard to get on a schedule?
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Years?
Months?
Before age2, did/does this child become anxious around strangers?
Years?
Months?
Before age 6, did/does this child like pretend play?
Before age 11, did/does this child understandthat a given quantrty remains the sameregardlessof its shape?
At age 12 or older, did /does this child use if - then reasoning?
Years?
Years?
Easygoing,quiet,regular,shy,timid, slow-to-warm-up?
Play the sameactivity as another,but separately?
Or do theyplay together,sharingandcooperating
YES
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Months?
Months?
NO
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DON'T KNOW
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PAST PSYCHOLOGICAL/PSCHIATRIC TREATMENT
Provider
Response
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Type of Evaluation
Hasthis child beenin a psychiakichospital?
Diagnosis?
Where?
When?
REVELANT FAMILY HISTORY
Who is living in your home presently? (pleaselist below)
Relationship
Pleaselist anyothersignificantpersonsin your child's life:
Name:
Sex:
Relationship:
Age:
Has any family member (siblings, parent, grandparents,aunts,uncles, cousins) had problems with:
Learning?
Attention/ADHD?
Moods?
Worries/Phobias?
Anger?
Manic-Depression?
Drugs/Alcohol?
Suicideattempts?
Abuse?
Troublewith police?
Nervousbreakdowns?
Obsessions/Compulsions?
Tics?Twitches?
YES
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NO
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DON'T KNOW
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We would like you to tell us aboutyour child's currentproblem(s). Pleasecircle onenumberfor eachproblem
listed, telling us how sigrrificantthat problemis at present.
PROBLEMSWITH
EATING AND SLEEPING
Doesn'teatright
Mild
No
Moderate
Problem Problem Problem
Serious
Problem
Extreme
Problem
t23
Refusesto go to bed
Trouble falling asleep
Nightmares
Wakesup too early
PHYSICALPROBLEMS
Doesn't speakwell
Not fully toilet trained (wet bed, soils, etc.)
Tired most of the time
Has achesand pains
Clumsy or accidentprone
Fakesbeing sic
No
Mild
Moderate
Problem Problem Problem
Serious Extreme
Problem Problem
L2
T2
SCHOOLPROBLEMS
Hasproblemslearningin school
Is afraid to go to school
Won't obey school rules
Often missesschool
RELATIONSHIPSWITH OTHERCHILDREN
Teasesotherchildren
Has few or no friends
Is pickedon by otherchil
Plays alone most of the time
Fights with other children
Hassexplay with otherchildren
1
1
Poor choice of friends
BEHAVIOR PROBLEMS
Usesdrugs
Runs away from home
Lies
Steals
Setsfires
Breaksthings
SOCIAL SKILLS
Afraid of manythings
Very shy
Poor loser
Demands too much attention
l2
2
2
3
4
5
OTHERPROBLEMSWITH RELATIONSHIPS
Talksbackto grown-ups,
Disobeysparents.
Can'tbe trusted
Hasa bad attitude
Doesn'ttrustotherpeople
1,2
EMOTIONAL PROBLEMS
Is sador unhappymuchof the time
Criesa lot
Has temper tantrums
Mood changesquickly without reason
OTHERPROBLEMS
No
Mild
Moderate
Problem
Problem
Problem
Has threatenedor attempted suicide
123
Serious Extreme
Problem Problem
45
Hurts self on purpose
Acts younger than real age
Can't sit still
Acts without thinkine
Wantsthingsto be perfect
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2
3
t2
Says or does strangeor peculiar things
Is often confused or in a daze
Daydreams a lot
Doesn't finish things (short attention span)
4
Any other information which you feel is important:
SIGNATUREOF PERSONCOMPLETINGFORM
RELATION TO CHILD
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